Location:California
Company Name :Hill Physician Medical Group
Job details:
The Authorization Nurse will evaluate authorization requests and authorize, modify or pend per appropriate criteria. They will also refer authorization requests not meeting criteria to specialty physician reviewers according to established medical necessity, benefit and eligibility criteria to assure appropriate, efficient and timely medical care.
Duration : Full Time
Pay: $103,000 – $108,000
Job Description/Overview:
- Review and process urgent and non-urgent authorization requests (via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate.
- Obtain additional medical information as necessary from the requesting provider.
- Communicate with providers and members regarding the status of authorization requests.
- Collaborate with Medical Directors and other designated physician leaders for making clinical decisions
Key Responsibilities:
- Review and process urgent and non-urgent authorization requests (via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate.
- Utilize a variety of medical necessity, contractual and benefit criteria to determine appropriate authorization decisions. Criteria may include MCG, Hill Guidelines, Health Plan Criteria, Health Plan and Hill Physician contracted provider data and member benefit information.
- Obtain additional medical information as necessary from the requesting provider.
- Communicate with providers and members regarding the status of authorization requests.
- Assist interdepartmental staff members to resolve issues relating to the authorization process.
- Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management, Health Education, TPL, COB).
- Process authorization requests (routine, urgent and retrospective) according to department performance standards.
- Support Medical Management team authorizations, clinical initiatives, provider education, and other special projects as assigned.
- Collaborate with Medical Directors and other designated physician leaders for making clinical decisions.
- Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.
- Perform other duties as assigned by supervisor/manager.
- Assist interdepartmental staff members to resolve issues relating to the authorization process.
- Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management, Health Education, TPL, COB).
- Support Medical Management team authorizations, clinical initiatives, provider education,
- Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements and other special projects as assigned.
Qualifications needed:
- Active, unrestricted California Licensure: Registered (RN)
Experience:
- 3+ years clinical nursing experience.
- 2-3 years of Utilization Management experience.
- Excellent verbal and written communication skills.
- Ability to work effectively with a variety of customers including physicians, office staff, and members.
- Ability to work independently with self-initiative and discipline.
- Working knowledge of personal computers.
- Managed care experience and certification preferred.
- Knowledge of ICD-10 and CPT coding.
- Optimum organizational skills with ability to meet expected and unexpected time frames.
- Previous experience with Epic Tapestry platform preferred but not required.
Additional information:
We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and one of the “Healthiest Places to Work in the Bay Area.” We have an award-winning Wellness Program, and our average tenure is ~8 years. Every person who joins Hill Physicians is coming in as a leader and has the very real potential to grow with the company as we grow. We’re all in it for the long haul and are bought-in to the success and future of our organization.
We’re proud to have been (and continue to be) a pillar of the Northern Californian healthcare community for more than 30 years. Our more than 5,000 primary care physicians and specialists provide high-quality care across the San Francisco Bay, Sacramento, and Central Valley areas.
By adapting to both the demands of the industry and the needs of consumers, we’ve remained stable and profitable, and our service area now ranges from the Pacific Ocean to the Sierra Nevada’s. We’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.
Our culture is guided by core values that promote the health and wellness of our employees and communities (health), commitment (accountability), fiscal responsibility (stewardship), teamwork (collaboration), and our dedication to do the right thing (integrity). 97% of employees feel that supervisors and managers “walk the talk” and demonstrate our core values. Join us!
Hill Physicians is an Equal Opportunity Employer.
401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Tuition reimbursement
- Vision insurance
Who can apply:
At Hill Physicians Medical Group, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.
We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it’s right!
Must reside in California for consideration.
Job link:
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